■ To combat a primary care shortage, the National Institute for Health Care Reform suggests payment overhauls and expanding APNs' scope of practice.

Efforts to increase the primary care work force, such as expanding medical school classes and offering incentives to those who go into primary care, aren't enough to meet growing demands for care, said a report from the National Institute for Health Care Reform.

Though such initiatives are important, it will be several years before the benefits are seen, said the nonprofit institute, which conducts research and analysis of health care organization, financing and delivery. The institute was established by the International Union, United Automobile, Aerospace and Agricultural Implement Workers of America; Chrysler Group LLC; Ford Motor Co.; and General Motors Co.

"Examining scope-of-practice laws and payment reforms to increase productivity of primary care practices may have a greater near-term impact on primary care supply," the report said.

Representatives of the American Medical Association and the American Academy of Family Physicians said they agree with the need to expand the primary care work force. But they questioned the institute's recommendation to expand APNs' practice scope.

"Increasing the responsibility of nonphysician health care professionals beyond their education and training is not the answer to this shortage," said AMA President-elect Jeremy A. Lazarus, MD. "Training more physicians and nurses so patients have access to the quality care they need is the answer."

Physician shortages nationwide are projected to reach 62,900 doctors by 2015 and 91,500 by 2020, according to 2010 projections from the Assn. of American Medical Colleges. The Health Resources and Services Administration estimates that 17,722 primary care practitioners are now needed in medically underserved areas to meet a target of having one primary care professional for every 2,000 U.S. residents.

The National Institute for Health Care Reform says broadening state scope-of-practice laws and allowing more APNs to practice independently would expand primary care capacity. Twenty-two states and the District of Columbia allow APNs to practice independently, said the report, which was written for the institute by the Center for Studying Health System Change, a Washington-based policy research organization.

"Expanding scope of practice is controversial and generates a lot of debate and advocacy from physicians and advanced practice nurses, both at the state and national levels," said Tracy Yee, PhD, MPH, a report co-author and health researcher with the Center for Studying Health System Change.

AAFP President Glen Stream, MD, said there is no evidence that expanding APNs' scope of practice would help reduce gaps in care. Even in states where APNs can practice independently, many choose to work collaboratively with physicians. APNs also tend to cluster in urban areas, just as physicians do, he said.

"Nurses are a very important part of the care team that we envision as part of our health care system," Dr. Stream said. "I think [the institute is] scratching the surface of a very complicated issue."